Mesothelioma medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Feham Tariq, MD [2]Sujit Routray, M.D. [3]

Overview

Chemotherapy is one of the mainstay of therapy for mesothelioma. Other therapies for mesothelioma include radiotherapy, surgery, and supportive care.

Medical Therapy

The treatment for mesothelioma depend on various factors, which include:

• Location of the mesothelioma
• Stage
• Resectability of the tumor
• Type of symptoms
• Overall health and performance status
• Performance status
• Age

The various treatment options for mesothelioma include:

Treatment of Mesothelioma

Supportive Care

Radiotherapy

Chemotherapy

Surgery

Supportive Care

Concern	Supportive Care
Loss of appetite	Small amounts of high-calorie foods or fluids, having smaller, more frequent meals, and nutritional supplements can be helpful. Anti-emetic drugs can be used to control nausea and vomiting. Cold foods may be better tolerated and using plastic cutlery can help if foods have a metallic taste. When appropriate, medicines may be prescribed to help increase appetite. Cachexia can occur in people whose mesothelioma is very advanced.
Shortness of breath	Pleural effusion is common with pleural mesothelioma, but can also occur with some peritoneal mesothelioma. Treatment options for pleural effusion may include: thoracentesis pleurodesis chest tube insertion to drain the fluid that has collected in the pleural space radiation therapy may be given, after thoracentesis, to try to prevent fluid from building up again Relaxation and breathing exercises may help with problems breathing. Oxygen therapy may be ordered to help relieve difficulty breathing.
Ascites	Peritoneal mesothelioma can cause ascites. Paracentesis may be done to relieve symptoms. Another option is to insert catheter to drain the fluid from the abdomen.
Pain	People with advanced mesothelioma may experience pain because the tumor grows into surrounding nerves and organs. The amount of pain often increases as the cancer advances. Pain may be managed by: External beam radiation therapy: Palliative radiation therapy may help relieve pain by shrinking tumors that press on nerves or other organs. Palliative surgery: Palliative surgery or procedures are not used to remove the tumor, but are done to relieve pain or other problems, such as pleural effusion or ascites. Palliative surgery or procedures may include: pleurectomy and decortication (P/D) thoracentesis pleurodesis paracentesis Pain-relieving medications: Pain medications are used, especially for advanced mesothelioma.
Fatigue	Poor appetite and trouble breathing can also make fatigue worse. It can be hard to cope when you are feeling very tired and don’t have a lot of energy, especially for a while after treatment or if the cancer is advanced.
Bowel obstruction	Bowel obstruction can occur in people with peritoneal mesothelioma. A bowel obstruction can cause abdominal pain, nausea, vomiting, and an inability to pass feces. Resting the bowel by not having anything to eat or drink, or feeding through a nasogastric tube placement may help, but surgery to remove the obstruction may be necessary.
Coping with advanced cancer	Mesothelioma is often diagnosed at an advanced stage. People with advanced mesothelioma are offered palliative care. This is a special type of care that focuses on making the person as comfortable as possible, relieving symptoms, providing support and improving or maintaining the person’s quality of life.
Financial concerns	People with mesothelioma may have financial concerns as a result of their illness. There are special services or benefits to help workers (and their families) who have developed mesothelioma from occupational exposure to asbestos. Conditions about exposure and legal processing of claims for asbestos-related cancers can differ by province or territory.

Chemotherapy

• Chemotherapy is one of the mainstay of therapy for mesothelioma. Many people are not diagnosed until the mesothelioma is advanced and hence not resectable. In these cases, chemotherapy is used to treat the disease and relieve symptoms. Drugs, doses, and schedules vary from individual to individual.
• Chemotherapy may also be a regional therapy given to specific areas of the body. Regional chemotherapy for mesothelioma may be given directly into a body cavity (intracavitary chemotherapy) that contains cancer including the:

• Chest cavity (intrapleural chemotherapy)
• Abdominal cavity (intraperitoneal chemotherapy)

• Chemotherapy may be used:

• As the main treatment to shrink the tumor and keep the cancer under control
• Who cannot have surgery because their cancer is unresectable
• With sarcomatoid subtype of mesothelioma
• Not well enough to tolerate surgery
• Who decide not to have surgery
• To relieve pain or to control the symptoms of advanced mesothelioma (palliative chemotherapy)
• After surgery to destroy cancer cells left behind and to reduce the risk of the cancer recurring (adjuvant chemotherapy)
• Before surgery to shrink a tumr ('neoadjuvant chemotherapy)

Chemotherapy Drugs

Common chemotherapy drugs used to treat mesothelioma include:

• Cisplatin
• Carboplatin
• Antifolate drug: pemetrexed, raltitrexed
• Gemcitabine: Gemcitabine may be given to people who cannot have platinum-based (cisplatin or carboplatin) combination chemotherapy.
• Vinorelbine: This drug may be also given to people who cannot have platinum-based combination chemotherapy or who have been treated previously with platinum-based combination chemotherapy.

Although a single drug may be used, better responses to chemotherapy occur when a combination of drugs are given for mesothelioma. Common chemotherapy combinations used to treat mesothelioma include:

• cisplatin and an antifolate drug

• cisplatin and pemetrexed – most common combination used
• cisplatin and raltitrexed

• carboplatin and an antifolate drug

• Carboplatin may be used instead of cisplatin, especially in older adults because it has less renal and nervous side effects than cisplatin.
• Drug combinations may include:

• carboplatin and pemetrexed
• carboplatin and raltitrexed

• cisplatin and gemcitabine
• carboplatin and gemcitabine

These combinations of drugs are given intravenously for 3–6 cycles. In some cases, they are given until the disease progresses.

Regional Chemotherapy

• Regional or intracavitary chemotherapy for mesothelioma may include:

• Intrapleural chemotherapy

• Chemotherapy drugs are injected through a chest tube or catheter into the pleural cavity.
• It is used to treat pleural mesothelioma.
• Intrapleural chemotherapy can be used to control pleural effusions.

• Intraperitoneal chemotherapy

• Chemotherapy drugs are injected into the peritoneal cavity.
• It is used to treat peritoneal mesothelioma.
• Peritoneal mesothelioma usually remains confined to the peritoneal cavity until late in the course of the disease. Giving drugs directly into the peritoneal cavity greatly enhances the concentration of drugs in that area and limiting side effects to the rest of the body.

• Sometimes regional chemotherapy is given right after surgery (in the operating room) or soon afterwards. Some of the drugs used as regional chemotherapy to treat mesothelioma include:

• Cisplatin
• Mitomycin
• Doxorubicin

• Regional chemotherapy drugs are sometimes heated before they are given (hyperthermic chemotherapy) to help them work better.

Radiotherapy

Radiation therapy may be used for mesothelioma:

• To relieve pain or to control the symptoms of advanced mesothelioma (palliative radiation therapy)

• Radiation therapy is most often used to relieve symptoms in people with advanced mesothelioma.
• Radiation therapy may be used in people who are unfit for surgery.

• After surgery to destroy cancer cells left behind and to reduce the risk of the cancer recurring (adjuvant radiation therapy)

• Radiation therapy is usually used after surgery, such as after extrapleural pneumonectomy for pleural mesothelioma. Radiation therapy is given to the side of the chest where the mesothelioma and lung were removed. This may be referred to as hemithoracic radiation.
• Radiation therapy is not usually used after pleurectomy and decortication (P/D) for pleural mesothelioma because of the large area that needs to be treated and the side effects that can occur due to radiation on the lung.

External Beam Radiation Therapy

Mesothelioma is usually treated with external beam radiation therapy. A machine directs radiation to the tumor and some of the surrounding tissue. A newer type of external beam radiation therapy, called intensity-modulated radiation therapy (IMRT), may be used to more accurately treat mesothelioma while reducing the amount of radiation to surrounding normal tissue. IMRT helps reduce side effects to normal tissue.

References

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